Tilt Training Research Articles

Refractory Vasovagal Syncope Despite Tilt Training: Should Paroxetine be Included in the Treatment?

Refractory Vasovagal Syncope Despite Tilt Training: Should Paroxetine be Included in the Treatment?

The Impact of Self-Care Recommendations with and without Tilt-Training on Quality of Life in Children and Adolescents with Vasovagal Syncope: A Randomized Clinical Trial.

Syncope is among the most common paroxysmal disorders in children and adolescents. Vasovagal syncope is the most common syncope in children and adolescents. The aim of this study was to evaluate the impact of self-care recommendations with and without tilt training on the Quality of Life (QoL) of children and adolescents with syncope. This randomized controlled clinical trial was conducted in Isfahan, Iran, from April 2017 to June 2021 and included 120 patients with syncope. Eligible children and adolescents (aged 6-18 years) who met inclusion criteria were recruited by the simple sampling method and then assigned randomly into two groups. The intervention group (n = 60) received routine self-care recommendations such as dietary advice, behaviors to prevent syncope, and counter-pressure maneuvers along with tilt training, while the control group (n = 60) received self-care recommendations without tilt training. The education training included two face-to-face sessions, each of which lasted for 45-60 min. Then, both groups were followed up by telephone (once a month) for six months. A researcher-made self-care questionnaire and Pediatric Quality of Life Inventory (PedsQL™ 4.0) were completed for both groups before and after the intervention. Data were analyzed using descriptive and inferential statistical methods. The Wilcoxon test results showed a significant difference in the mean scores of physical functioning, emotional functioning, social functioning, school functioning, psychosocial functioning, understanding of health, and total QoL in the intervention and control groups before and after the intervention (p < 0.05). Also, the paired t-test results showed a significant difference in the mean scores of self-care domains and total self-care in the intervention and control groups before and after the intervention (p < 0.05). Self-care recommendations with and without tilt training can improve QoL in children and adolescents with syncope.

Immediate effects of lateral truncal tilt balance training with and without a wedge on subjective postural vertical and sitting balance in patients with subacute stroke: a randomised crossover trial

Background/Aims The subjective postural vertical is an important factor in maintaining sitting balance. However, specific training to improve verticality and sitting balance has yet to be established. The aim of this study was to clarify the effectiveness of lateral truncal tilt training, using a wedge, on subjective postural vertical, subjective postural vertical with eyes open and sitting balance in patients with subacute stroke. Methods In this randomised crossover trial, the immediate effects of lateral truncal tilt training were examined. Participants were allocated to one of two groups (group 1 and group 2). In group 1, after placing an inclined 10° tilt wedge on the participants' affected side, the participants moved their trunk laterally as far as possible toward the wedge side 60 times within 2 minutes. The participants in group 2 performed the same movement but without the wedge. This was performed once. The participants' subjective postural vertical, subjective postural vertical with eyes open and sitting pressure while they were tilted toward the frontal plane were measured at baseline, after the first intervention and after the second intervention. Following a 1-hour break, the groups crossed over. Repetition analysis was used at baseline and after both groups had competed the intervention both with and without the wedge. Results In total, 18 patients (mean age 68.7 years) participated in this study. Variabilities in subjective postural vertical with eyes open indicated a greater decrease in group 1 than group 2 (P&lt;0.01). A significantly larger improvement in the balancing capabilities in the subjective postural vertical and sitting pressure was observed (P&lt;0.01). The sitting pressure on the affected side in the subjective postural vertical with eyes open and subjective postural vertical showed a pre- and post-training interaction (P&lt;0.01). Conclusions Lateral truncal tilt balance training using a wedge can improve postural verticality and improve sitting balance in people who have had a stroke. Implications for practice Stroke rehabilitation programmes can include wedge training to improve posture and sitting balance in people who have had a stroke, which can help these individuals to complete activities of daily living.

The efficacy of non-pharmacological and non-pacing therapies in preventing vasovagal syncope: Tilt training, physical counter pressure maneuvers, and yoga - A systematic review and meta-analysis

BackgroundVasovagal syncope (VVS) is a prevalent condition characterized by a sudden drop in blood pressure and heart rate, leading to a brief loss of consciousness and postural control. Recurrent episodes of VVS significantly impact the quality of life and are a common reason for emergency department visits. Non-pharmacological interventions, such as tilt training, physical counter pressure maneuvers, and yoga, have been proposed as potential treatments for VVS. However, their efficacy in preventing VVS remains uncertain. MethodsA systematic review and meta-analysis were conducted following PRISMA guidelines. PubMed, Web of Science, and Embase were searched up to March 2023 for randomized controlled trials comparing non-pharmacological interventions with control in preventing VVS recurrence. The primary outcome was the recurrence rate of VVS episodes. ResultsA total of 1130 participants from 18 studies were included in the meta-analysis. The overall mean effect size for non-pharmacological interventions versus control was 0.245 (95 % CI: 0.128–0.471, p-value <0.001). Subgroup analysis showed that yoga had the largest effect size (odds ratio 0.068, 95 % CI: 0.018–0.250), while tilt training had the lowest effect size (odds ratio 0.402, 95 % CI: 0.171–0.946) compared to control. Physical counter pressure maneuvers demonstrated an odds ratio of 0.294 (95 % CI: 0.165–0.524) compared to control. ConclusionNon-pharmacological interventions show promise in preventing recurrent VVS episodes. Yoga, physical counter pressure maneuvers, and tilt training can be considered as viable treatment options. Further research, including randomized studies comparing pharmacological and non-pharmacological approaches, is needed to evaluate the safety and efficacy of these interventions for VVS treatment.

Medium-term effects of lateral truncal tilt training with a wedge on trunk function and balance abilities in severe stroke patients: A randomized crossover clinical trial

Medium-term effects of lateral truncal tilt training with a wedge on trunk function and balance abilities in severe stroke patients: A randomized crossover clinical trial

Advances in Treating Vasovagal Neurocardiogenic Syndrome: A Comprehensive Review of Medical Interventions

Neurocardiogenic vasovagal syndrome (VVS) is a common clinical condition that results in a transient loss of consciousness and inability to maintain posture, with a rapid and spontaneous recovery. Considering the technological advances regarding the effectiveness of different treatments for VVS, this article aims to review the treatment options available in the medical literature to better understand the treatment options and their potential benefits. This study is a literature review of the medical literature focused on publications from 2005 to 2022 related to the therapeutic management of VVS. Digital databases such as PubMed and SciELO were searched using the descriptors &amp;ldquo;vasovagal syncope&amp;rdquo;, &amp;ldquo;neurocardiogenic syncope&amp;rdquo; and &amp;ldquo;treatment of vasovagal syncope&amp;rdquo; to identify relevant studies. Orthostatic training (or tilt training) is a non-pharmacological approach that involves postural training performed through multiple sessions of orthostasis. Tilt training (TTr) proved to be an effective therapeutic method with long-term benefits in refractory patients. Pharmacological treatment should be considered in a case-by-case scenario. Cardioneuroablation is a procedure that has been shown to eliminate or significantly reduce the vagal response, leading to symptom relief in up to 75% of patients. Results showed that implementing a definitive pacemaker reduced symptoms in at least one-third of patients. In summary, treatment strategies for VVS are evolving with advances in medical research, allowing for a thorough analysis of each modality to determine its suitability. It is crucial to emphasize that the selection of treatment options should be evaluated by a specialist individually to ensure effective management of the patient&amp;rsquo;s clinical manifestations. Thus, available interventions have the potential to improve patient&amp;rsquo;s quality of life significantly.

P452 VASOVAGAL SYNCOPE AND COVID–19

Abstract Scope. The aim of the study was to evaluate how the Covid–19 state of emergency affected the activity of the Syncope Unit (SU). During the lockdown, the outpatient activities of the SU were suspended(1). Materials. From March 2020 to March 2021, approximately 95 patients booked for the Tilt–up test were medically evaluated by teleconsultation and televiewer. Vasovagal syncope (VVS) (61%), orthostatic hypotension (OH) (5%) was diagnosed. The patients were trained, through television and video tutorials, in the use of counter pressure maneuvers (PCM) and tilt training, while dietary indications were provided and the importance of adequate oral hydration and the need to take, as recommended by the guidelines, 2–3l of water per day. We retrospectively observed the result at the end of the lockdown period: patients with VVS and OH called by the SU no longer needed to perform tilt up tests because they had obtained a significant reduction in syncope in 90% of cases. Discussion Reflex syncope is the most frequent, representing 21% of all types of syncope (2). Accurate history and physical examination are necessary for the diagnosis, sometimes a guided path in the SU in the unexplained forms. The indicated therapy is non–pharmacological (increase the salt and water content in the diet, avoid triggers, tilt training)(2) and, especially in young people, has been shown to prevent recurrences(2). Back pressure maneuvers (PCM) are effective in preventing syncope(3); oral hydration increases blood volume and improves symptoms(4). Conclusions The Covid–19 state of emergency, through the use of telemedicine tools, has made it possible to reach the diagnosis of reflex syncope through an accurate anamnestic evaluation, has allowed patients to be reassured about the benignity of the events and has motivated patients to implement the recommended non–pharmacological therapies. This has made it possible to reduce the number of tilt tests to be performed when the SU reopens.

Effectiveness Of Pelvic Tilt Training Vs Core Strengthening For Chronic Lumbar Radiating Pain.

Effectiveness Of Pelvic Tilt Training Vs Core Strengthening For Chronic Lumbar Radiating Pain.

Autonomic response to early head-up tilt in patients with severe traumatic brain injury: Analysis from a randomized feasibility trial.

Patients with severe traumatic brain injury (TBI) may have autonomic dysfunction, one manifestation of which is orthostatic intolerance. This potentially impairs physical rehabilitation. However, the exact mechanisms remain elusive. In 30 patients participating in a trial of early tilt training versus standard care and 15 healthy volunteers, 5-min electrocardiography was recorded in the supine position and during 70° head-up tilt. Heart rate variability was analyzed by the low- and high-frequency (LF and HF) power, the LF-HF ratio, the total power, the ratio of the standard deviation of normal-to-normal intervals (SDNN), the root mean square of successive differences (RMSSD), the detrended fluctuations, and sample entropy. In patients in the upright compared to the supine position, SDNN (p < 0.001), RMSSD (p < 0.001), and total power (p = 0.004) all decreased, while the remaining variables were unchanged; no long-term differences in heart rate variability in the supine position were found between early tilt training and standard care. In the healthy volunteers, all measures besides SDNN and total power changed significantly between supine and upright position. In patients with severe TBI compared to healthy volunteers, several measures of heart rate variability changed differentially during mobilization from the supine to the upright position.

Efficacy of lateral truncal tilt training with a wedge on postural vertical and activities of daily living in recovery phase after stroke: A randomized crossover trial.

The subjective postural vertical (SPV) is affected by training that requires participants to maintain balance; training to achieve sitting balance may also help SPV recovery and activities of daily living (ADLs). This study aimed to assess the medium-term effects of balance training on the postural vertical (PV) and ADLs in patients with stroke. Thirty-three patients with stroke were enrolled in this randomized crossover trial. The outcomes were SPV, SPV with eyes opened (SPV-EO), and the Functional Independent Measure (FIM) after the 14-day intervention of experimental or control training. Experimental training consisted of a maximum lateral truncal tilt to the paretic side at 0.25 Hz with or without a 10° wedge, repeated 60 times. Repeated-measures two-way analysis of variance was performed with two factors: intervention and the intervention period. There was no interaction between the control condition and the PV, but there was interaction between the intervention period and using a wedge for SPV variability errors. FIM showed an interaction between the intervention period and the use of a wedge. Balance training while sitting with a wedge significantly improved the SPV and FIM. This improved cognition and perception, which facilitate difficult dynamic tasks in ADLs.

EFFECTS OF HEAD DOWN TILT TRAINING ON CAROTID BLOOD FLOW, PSYCHOLOGICAL STRESS AND ANXIETY SENSITIVITY IN THE ELDERLY

EFFECTS OF HEAD DOWN TILT TRAINING ON CAROTID BLOOD FLOW, PSYCHOLOGICAL STRESS AND ANXIETY SENSITIVITY IN THE ELDERLY

Implementation of supervised physical training to reduce vasovagal syncope recurrence: A randomized controlled trial.

Physical techniques used for the prevention of vasovagal syncope have limited evidence for efficacy. We aimed to evaluate multimodal supervised physical training as a treatment approach. In this 1:1 randomized trial, patients with ≥2 episodes of clinically diagnosed vasovagal syncope were included. On top of standard care, the intervention arm performed supervised tilt training and aerobic exercise in six sessions at a cardiac rehabilitation center (three sessions during the first month, and then at 3-month intervals), plus home tilt training. The control arm received standard care with a similar protocol of home tilt training. The primary outcome was time to first syncopal recurrence during 1year of follow-up. Fifty participants were randomized (mean age: 34.5 ± 14.8 years; 64% female). The rate of syncopal recurrence was 28% and 64% within the intervention and control arms, respectively, with significantly higher syncope-free survival at 1year in the intervention arm (Log-rank p = .003). The frequency of recurrent syncopal events was significantly lower with physical training (p = .017). Participants in the intervention arm reported significantly higher adherence to the home tilt training program (80% vs. 52%; p = .037). Among patients with recurrent vasovagal syncope, a supervised program of tilt training and aerobic exercise reduced syncopal recurrence. Future trials are warranted to further investigate multimodal supervised physical techniques as a therapeutic approach in treating vasovagal syncope.

Protocolo terapéutico del síncope en urgencias

Syncope can be classified as reflex (neuromediated) syncope, syncope due to orthostatic hypertension, or syncope secondary to cardiovascular pathology. Given that reflex syncope has a good prognosis, treatment is essentially aimed at preventing recurrence. The diagnosis must be explained to all patients and they must be reassured and advised on the risk of recurrence and how to avoid triggering situations and factors. Isometric counterpressure movements in the upper and lower limbs can avoid onset of syncope once symptoms have begun as well as prevent falls. Tilt training can be considered for instructing young patients. In patients with very recurrent episodes of the orthostatic form of vasovagal syncope, administration of fludrocortisone or midodrine can be considered. Syncope due to orthostatic hypotension tends to occur in elderly patients and those with hypotensive treatment. We must first adjust hypotensive treatment. Intake of 400 - 500ml of water three to four times per day can help in both reflex and orthostatic hypotension syncope. Cardiogenic syncope occurs in patients with underlying cardiopathy or an abnormal electrocardiogram. It tends to have a poor prognosis and its end mechanism must be understood in order to establish treatment.

Impact of supervised physical training on vasovagal syncope; a randomized controlled trial

Abstract Background Therapeutic interventions in vasovagal syncope (VVS) are centered on lifestyle modifications aimed to counteract the recognized mechanisms that precipitate syncope. In patients with recurrent VVS, supervised training might help reduce the symptomatic burden by increasing adherence to lifestyle modifications. Purpose We aimed to evaluate the effect of an integrated supervised training program versus standard care on syncopal recurrence rate among patients with VVS. Methods This randomized, controlled, 1:1 parallel-design, open-label trial was conducted between November 2019 and February 2021. Eligible patients were those aged between 18 and 70 years with newly-diagnosed medication-naïve VVS who had experienced ≥2 syncopal episodes in the prior year. All participants received education and reassurance about the benign nature of VVS, were advised to increase salt and fluid intake, and practice counter-pressure maneuvers based on 2018 European Society of Cardiology syncope guideline (standard care). Patients were randomized to standard VVS care or the training program. The intervention program consisted of thrice-weekly four-hours-long sessions during the first month after randomization; including tilt training, aerobic exercise (with rowing ergometer, recumbent biking), and standardized counter-pressure maneuvers supervised by a team of physical medicine and rehabilitation specialist and a cardiologist. After the first month, the intervention group were planned to attend a four-hours-long session every three months. The control group were followed by phone calls after the initial visit every three months. The intended follow-up duration was one year and the primary outcome was time to first syncopal episode. Results Out of 332 patients screened, 50 (mean age: 33.5 years; 64% female, figure 1) were equally randomized. Follow-up was completed for all participants. After one year, there was a significant reduction in syncope with supervised training compared to standard care (hazard ratio: 0.28; 95% confidence interval: 0.11 to 0.68; p=0.005, figure 2). Furthermore, frequency of syncope was lower in the supervised training arm versus standard of care (median [interquartile range]: 0 [0–1] versus 1 [0–3]; p=0.017). Conclusions In patients with recurrent VVS, supervised training showed promising results in reducing syncopal recurrence. Future research should focus on similar approaches to alter patients' lifestyle as an effective treatment for VVS. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Tehran University of Medical Sciences Figure 1Figure 2

Pelvic Tilt Exercise Against Lower Back Pain For Third Trimester Pregnant Women In Rejang Lebong Regency

Changes that occur during pregnancy may be difficult during pregnancy and during childbirth. Complications during pregnancy include back pain, low back pain, pelvic pain, and shortness of breath. One of the most common discomforts is back pain. Back pain is the most common musculoskeletal problem in pregnant women. It is estimated that 50% to 70% of pregnant women suffer from this problem. The purpose of this study was to determine the effect of pelvic tilt training on the reduction of back pain in third-trimester pregnant women in the Rejang Lebong Regency. The research variable was back pain in third-trimester pregnant women measured before and after pelvic tilt exercises. The research was conducted in May-July 2020. This type of research is Quasi-Experimental, the results of the sample calculation obtained a sample of 32 people. The statistical test used to see the reduction in back pain before and after Pelvic tilt exercise is non-parametric Wilcoxon. Results of back pain in the third trimester of pregnant women after being given pelvic tilt exercise with p &lt;0.005. There is a difference in back pain in the third trimester of pregnant women after pelvic tilt exercises.

Role of tilt-table testing in syncope diagnosis and management: analysis of patients referred to a syncope unit

Abstract Introduction Head-up tilt-testing (HUT) enables the reproduction of reflex syncope in a laboratory setting. Despite being used to confirm the diagnosis of this syncope, there is some concerns regarding the best protocol to use and recent studies with implantable loop recorders have called the value of HUT into question. Aim To characterize the population undergoing HUT according to the modified Italian protocol, type of response to HUT and subsequent management at our center in the last 4 years. Methods Retrospective analysis of consecutive P who underwent HUT between 2015 and 2018. Descriptive analysis of patients (P) demographics and medical history, indication for HUT, type of response to HUT and management. Results A total of 419P (55.1% female) were included with a mean age of 62 years. The majority (n=302, 72.1%) had comorbidities (structural heart disease – 55%, cardiac dysrhythmias – 57.6%, hypertension – 48.3%, diabetes – 15.6%, depression – 15.9%, cerebrovascular disease –10.6%) or was under medication (n=220, 52.5%) with a potential hypotensive or bradycardic effect (44.1% ACEI/ARA, 29.1% beta-blocker, 27.7% diuretic, 23.6% antidepressant, 22.7% calcium channel blocker, 19.1% benzodiazepines). Syncope/presyncope episodes accounted for 56.1% of the HUT, with falls and disequilibrium accounting for 52%. In 21 cases (5%) suspected dysautonomia or other non-specified reasons were the indication for HUT. HUT were ordered according to the guidelines in 136P (84.6% – indication level I, 3.6% – level IIa, 11.8% – level IIb). HUT was positive in 292P (69.7%) – 77.1% after nitroglycerin administration (vasodepressor – 170P, cardioinhibitory – 53P, mixed – 62P and dysautonomic – 7P). Cardioinhibitory (CI) response predominated in the younger, and vasodepressor in the older P. Of the P with CI response, 41.5% had asystole (median of 41.4s, minimum 7.5s, maximum 115s). All P were instructed in the need to avoid triggering factors and perform counterpressure maneuvers. A pacemaker was implanted in 24P (5.7% of all population, due to long sinus pauses and asystole). Twenty-four P (5.7%) completed a tilt training program. Conclusion Most of the HUT were requested for syncope/presyncope, frequently according to the guidelines. There was a high rate of positive tests, with a predominance of vasodepressive response, particularly in the elderly. Funding Acknowledgement Type of funding source: None

The effect of Draw-in Pelvic Tilt Training Onset Times of Core Muscle and Postural Control in Adults Hemiplegic Patients

Objective: The objective of this research is to conduct a 4week study on two groups of stroke patientsdraw-in pelvic tilt training Group and general...

Different patterns of tilt-table test outcome in children and their response to medications

Background Syncope is a common and often frustrating clinical problem encountered by pediatricians in outpatient or emergency room settings. Neurocardiogenic syncope is believed to be the most common cause of syncope in the absence of structural heart disease. In our study, we aimed to study different responses to tilting-table test among children and teenagers with suspected neurocardiogenic syncope. Patients and methods We collected data from patients of Ain Shams Hospital who presented with more than two attacks of syncope and got positive tilt-table test findings. All the patients were subjected to thorough history taking, full cardiac examination, and a tilt-table test. Patients were later followed up for 2 months for recurrence. Results Our study included data from 30 patients, of which 19 were females, and seven were on antiepileptic drugs. Approximately 20% of patients had a family history of epilepsy, and 10% had a family history of syncope. Prolonged standing especially in hot weather was the most common predisposing factor for their syncopal attacks. Palpitation and dizziness were the most common symptoms occurring before the attack, whereas palpitation and headache commonly affected these patients after syncope. Physical examination of these patients revealed no specific abnormality, and their hemoglobin level and random blood sugar level also revealed no specific abnormality. Tilt-table test was done to all the patients and revealed that ∼75% showed a vasodepressor response; however, only ∼23% showed a mixed response and no patients demonstrated cardioinhibitory response. No complications were reported during the test. The study revealed a significant negative correlation between the frequency of the attacks and initiation-response lag (r=−0.676, P&lt;0.001), meaning that the more the attack numbers of syncope, the earlier the occurrence of positive response in tilt-table test. All patients in the study received midodrine tablets together with diet modification and tilt training for 2 months. They were followed up for recurrence of syncope and only ∼16% of these patients showed recurrence. On asking patients with recurrence, they stated that they were noncompliant neither to the treatment nor to the exercise. Conclusion It is evident that tilt-table test is a safe and effective test to diagnose neurocardiogenic syncope in children and teenagers and that vasodepressor response is more common than both mixed and cardioinhibitory responses in children and teenagers. Midodrine, diet modification, and tilt training are effective management of neurocardiogenic syncope in children and teenagers.

Amount of Weight-Bearing During Tilt Table Inclination, With Neutral and Unilateral Knee Flexion Postures.

ObjectiveTo analyze the amount of weight-bearing during tilt table increments, with a review of neutral and unilateral knee flexion postures.MethodsThere were 17 healthy participants enrolled in this study. The subjects were tilted from 10° to 90°, and their body weight was measured at each 10° increment. In the first test, both plantar pressures, with the subjects in neutral posture, were recorded. During the second and third tests, the angle of inclination was thus recorded and increased, with the subjects in unilateral knee flexion posture; flexion was maintained at 25° by attaching a cylindrical support to the tilt table at the level of the popliteal fossa.ResultsThe study was divided into two types of postures: neutral and unilateral knee flexion. The percentage of body weight (%BW) between each leg during neutral posture was noted as not being statistically significant. The %BW of one side during tilt table inclination was significantly different between the two postures at 10° to 80° (p<0.05). The weight during unilateral knee flexion posture was lower as analyzed, regardless of tilt table inclination compared with that in neutral posture. We note that fifty percent of the ratio of %BW was noted at 33.12° and 38.76° in neutral and flexion postures, respectively.ConclusionThe unilateral knee flexion could induce the effect of decreased body weight compared with non-flexion side. The results of this study will help in setting a safe and quantitative percentage of weight-bearing on the lower extremity during tilt training.

P1791Clinical effect of home tilt training and its impact on the function of the autonomic nervous system in patients with reccurent vasovagal syncope

P1791Clinical effect of home tilt training and its impact on the function of the autonomic nervous system in patients with reccurent vasovagal syncope